Gastroenterology Coding Alert

Even though an incomplete endoscopic retrograde cholangiopancreatography (ERCP) can take a long time, there is no policy from either CPT or Medicare on how to report one. Lacking national guidelines, many gastroenterology practices have developed their own methods for coding these procedures, some of which may not ethically maximize their reimbursement dollars.
 
The lack of a coding policy makes it difficult even to determine a complete and an incomplete ERCP. Most ERCPs are not finished due to the gastroenterologist's inability to cannulate the ampulla of Vater because it's blocked or can't be found. However, a blockage further up in the patient's esophagus may also cause the procedure to be terminated, or the sedation could wear off on a patient, causing him or her to become combative.
 
"What makes this such a difficult issue is that there is no policy to tell you how far the endoscope has to advance like there is with a colonoscopy," says Barb Kallas, billing specialist for Gastroenterology Consultants, a practice with 10 gastroenterologists in Milwaukee.
 
Indeed, the AMA's CPT states that an endoscope must advance past the splenic flexure to be considered a complete colonoscopy. If the endoscope does not advance past that point, the procedure is considered a flexible sigmoidoscopy regardless of the fact that a colonoscope is used instead of a sigmoidoscope. In addition, Medicare has a national policy for billing incomplete colonoscopies by attaching modifier -53 (Discontinued procedure) to diagnostic colonoscopy code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). Medicare's Physician Fee Schedule database even has an established relative value unit (RVU) for 45378-53.
 
Kallas adds, "With an EGD [esophagogastroduodenoscopy], you are also told how far the scope has to advance or else it's not an EGD."
 
Although there isn't a specific policy for reporting an incomplete EGD, the CPT definition for the procedure makes it clear that the endoscope must advance beyond the patient's stomach and into either the duodenum or the jejunum to bill EGD code 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). If the endoscope does not advance to the duodenum or the jejunum, the esophagoscopy code 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) must be billed instead.

There is nothing in writing from either CPT or Medicare as to what constitutes a complete ERCP. Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, uses a definition provided by the medical coding publisher Medicode. "In order to be a complete ERCP, the ampulla of Vater must be cannulated and filled with contrast so that the common bile duct and entire biliary tract are visualized," she says. In her practice, an incomplete ERCP is one where the gastroenterologist cannot cannulate the ampulla of Vater. The physician should also be able to visualize either the bile or pancreatic ducts, and it should be documented.

Many gastroenterology practices have adapted the basics of Medicare's incomplete-colonoscopy policy, attaching modifier -53 to the diagnostic code, when reporting any kind of incomplete ERCP. "We put modifier -53 on the basic ERCP code (43260) and send along the documentation just to play it safe," Kallas says. "We usually receive 50 percent of the standard fee for an ERCP."
 
Other practices have decided to report EGD code 43235 because the side-viewing duodenoscope usually used during an ERCP travels along the same path through the gastrointestinal tract as the endoscope in an EGD until it reaches the duodenum. Therefore, many gastroenterology practices take the view that since the endoscope advanced as far as it would for an EGD, an incomplete ERCP can be billed as an EGD.
 
Unfortunately, there's such a disparity in the RVUs for the two procedures that gastroenterologists who report the EGD code may be shortchanging themselves. According to the Medicare Physicians Fee Schedule database, the standard, unadjusted fee for ERCP code 43260 is approximately $316. The standard, unadjusted fee for EGD code 43235 is about $136. Note that Kallas' practice receives about $158 by reporting the ERCP with modifier -53 attached.
 
Another way to code for an incomplete ERCP is to take a two-tiered approach. "It depends on what's in the operative note," Parks says. "If the gastroenterologist can't do the cannulation or is unable to visualize both the bile duct or pancreatic duct, we report 43260 with modifier -53 attached. If the endoscope can't get past the duodenum, we bill for an EGD."
 
Parks finds that her payers will usually pay 100 percent of the standard fee for either the incomplete ERCP with modifier -53 or the EGD.

Even if the ERCP is incomplete, the gastroenterologist could spot a polyp or lesion to biopsy in another part of the gastrointestinal tract such as the esophagus. In that situation, both Kallas and Parks would change their coding strategies. Instead of billing for an incomplete ERCP, Kallas would report an EGD with biopsy (43239) because the operative report will show that the gastroenterologist used an EGD endoscope in addition to the side-viewing endoscope for the ERCP.
 
"I might consider adding modifier -22 [Unusual procedural services] to the EGD code," Kallas says. "Because of the attempted ERCP, the gastroenterologist is probably going to spend close to two hours on the procedure instead of the usual 40 minutes for an EGD with biopsy. But you don't usually get paid or paid much for using modifier -22."
 
Precisely because two different endoscopes are usually used during the procedure, Parks would report both an incomplete ERCP (43260) with modifier -53 and the EGD with biopsy (43239). "These are bundled together in the Correct Coding Initiative (CCI) edits, so you need to add modifier -59 [Distinct procedural service] to the EGD with biopsy to indicate that these are separate procedures," she explains.
 If the gastroenterologist was able to perform the biopsy with the side-viewing ERCP endoscope, Parks would then bill for an incomplete ERCP with biopsy by reporting 43261-53.

It isn't unusual for a gastroenterologist who cannot cannulate the ampulla of Vater to have the radiologist who is usually present during the ERCP insert a percutaneous transhepatic cholangiogram (PTC) catheter in the patient. The ERCP endoscope is then reinserted in the patient, and the procedure is completed.
 
Under this scenario, Parks would only bill an ERCP and not even report the first attempt. She might add modifier -22 to the ERCP for the extra time the gastroenterologist spent trying to cannulate the first time. While many gastroenterology practices might be tempted to bill for the attempted ERCP and the completed procedure, payers will probably get confused by seeing the same procedure twice on the same day and probably reject the entire claim, Parks cautions.
 
Others might report this by billing EGD code 43235 for the attempted ERCP in addition to the appropriate ERCP code. The problem with this approach is that the diagnostic EGD code is bundled into most ERCP codes in the CCI edits. Therefore, it may not be appropriate to unbundle them especially if only the side-viewing ERCP endoscope is used during both procedures. Many payers will only reimburse for the lesser-valued EGD procedure, which has a much lower value than the ERCP.

Another situation that several Gastroenterology Coding Alert readers have experienced is an incomplete ERCP on a patient who has had a gastric bypass procedure such as a Billroth where the small bowel is divided and the stomach is rendered nonfunctioning by the bypass. Because the ERCP endoscope does not travel the usual route from the esophagus through the stomach to the duodenum, there is a question of what should be billed.
 
"If it is an attempted ERCP that just couldn't be cannulated, bill an incomplete ERCP with modifier -53," Parks advises. "It doesn't matter if the stomach was bypassed because it doesn't affect the bile duct. It's probably a harder procedure to do anyway."
  
Depending on at what point the ERCP was discontinued, it is possible that no endoscopic procedure can be reported at all. The patient may have a bad reaction to being sedated, for example, and the procedure is discontinued before an endoscope is even inserted. In this instance, the only service that can be billed is an E/M, probably an office/outpatient visit (99212-99215) unless the patient has been admitted to the hospital, Kallas says. The E/M service billed will depend on the level of history, examination and medical decision-making performed by the gastroenterologist.